Arthritis (Joint Pain)

Arthritis is inflammatory condition of Joints (Arthro – Joint; It is – Inflammation).

It causes chronic pain, swelling and stiffness. More than 200 different conditions affect joints and lead to Arthritis. From 2013 to 2015, an estimated 54.5 million people were diagnosed to have Arthritis (22.7 %) in USA.1 in 4 people with Arthritis, they have work limitations.

Type of Joints in Human body

1. Synarthroses (Syn- Fixed , Arthro- joint )- Fused joints with no movement.

Fibrous Joints

2. Slightly Movable Joint or Amphiarthroses

Cartilaginous

3. Freely Movable / Synovial Joints / Diarthroses

Highly mobile joints.

Figure 1. Joint Types

Common Diseases that affect joints

Rheumatoid Arthritis

RA is the most common inflammatory arthritis . It can occur at any age but peaks at 30-50 years. It has genetic predisoposition.Older age , smoking and femae sex are other risk factors.

They present with pain, stiffness, deformity and disability to work and movemet.

2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria for RA

Whom to screen 1.with one joint with clinical synovitis 2.with synovitis not better explained by other disease
Score equal or more than 6 through following categories needed to diagnose RA	Sore
A.Joints Involved
One large joint Involved	0
Two to large 10 joints	1
One to three small joints (may or not be large joints )	2
Four to ten small joints (may not be large jonts)	3
10 or more joints ( with at least one small joint )	5
B. At least one parameter is needed for classification
Negative Rheumatoid Factor (RA-Factor) and Anti Citrullinated Phosphate Antibody (ACPA)	0
Low positive RA or ACPA	2
High positive RA or ACPA	3
C.Acute Phase Reactant (at least one is needed for classification )
Normal CRP or ESR	0
Abnormal CRP or normal ESR	1
D. Duration of Symptoms
Less than 6 weeks	0
Equal or more than 6 weeks	1

After confirming the diagnosis of RA, people are treated with the following methods .

1.Non pharmacologic Treatment

Use of braces to prevent deformities.

2. Pharmacologic treatment

If treated earlier with medications, they have less damage to the joints and hence have better long term result.

A. DMARDs (Disease Modifying AntiRheumatic Drugs)

Methotrexate , Sulfasalazine , Hydroxycholoroquine, Leflunomide, Azathioprine

B.Biologic Agents

B.TNF Inhibitors

Anakinra, Abatacept, Rituximab, and Tocilizumab.

C.Kinase Inhibitors

Tofacitinib and Baricitinib

Combining DMARDS with Biologic agents improves efficacy of the drugs.

3. Surgery

Joint replacement for the deformed destructed and painful joints.

Gouty Arthritis

This is one form of inflammatory arthritis caused by crystals of Mono-Sodium Urate usually affecting one joint mostly ball of great toe. It presents with pain, swelling and redness of the joint. There might be periods of flare up and quiescence. Repeated attacks may lead to tophi formation which makes appearance ugly. It may also form on posterior elbow, ear pinna and over hand.

Figure 2. Tophi of Gouty Arthritis

Risk factors for Gouty Arthritis

Male

Obesity

Alcohol intake

Drugs – Diuretics (water pills)

Certain medical conditions

Congestive Heart Failure

Insulin resistance

Metabolic Syndrome

Diabetes

Poor kidney function

Diagnosis

Largely based on history of sudden onset swelling and pain on one joint , hot swollen one joint on examination and higher Serum Uric acid level are helpful to diagnose this.X-ray of the foot is done to rule out other causes of joints pain.

Treatment

1. Life style modification

Avoid alcohol, food rich in purines like red meat, sea foods

2. Manage flares

NSAIDs (e.g. Indomethacin)

Colchicine

3. Prevent future attacks for frequent flare ups and kidney stones

Allopurinol, Febustat , Pegloticase

Septic Arthritis

It’s a surgical Emergency. There will be bacterial infection to the joints. Usually it also presents with sudden onset of swelling of one joint. Bacteria strain are different with different age groups. Staphylococcus Aureus is the commonest organism to invade the joints in all age groups

Diagosis is confirmed with High White Blood Count (WBC), C-reactive protein (CRP), and Erhythrocyte Sedimentation rate (ESR). Positive culture confirms the diagnosis but it takes time and culture yield is only around 50 %.

Treatment

1. Splinting the extremity to minimize pain

2. Joint tapping and immediate Intravenous antibiotics targeting the organism

Usually penicillin or Cephalosporin group of antibiotics

3. Joint irrigation and Surgical Drainage of Pus

Osteoarthritis

Infact it’s the most common joint disorder in USA. Its prevalence is 10 % in men and 13 % in women older than 60. Female gender, Old age, overweight and obesity, knee injury, repetitive use of joints, bone density, muscle weakness, and joint laxity risk the joint for developing Osteoarthritis.

It most commonly affects hands, knees, hips and spines. They present mostly with pain, swelling, and deformity.

Dignosis is based on history and physical examination. X-ray of affected joints show the Joint space narrowing, Osteophytes, Cysts and Sclerotic changes on articular margins.

Xray normal knee , abnormal knee